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Evaluation and Treatment of Selected Sacral Somatic Dysfunctions

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Evaluation and Treatment of Selected Sacral Somatic Dysfunctions Using Direct and HVLA Techniques including Counterstrain and Muscle Energy AND Counterstrain Treatment of the Pelvis and Sacrum F. P. Wedel, D.O. Associate Adjunct Professor in Osteopathic Principles and Practice A.T. Still University School of Osteopathic Medicine in Arizona, and private practice in Family Medicine in Tucson, Arizona Learning Objectives HOURS 1 AND 2 Review the following diagnostic and treatment techniques related to sacral torsion Lumbosacral spring test Sacral palpation Seated flexion test HOURS 3 AND 4 Counterstrain treatments of various low back pathologies Sacral Techniques Covered : 1. Prone, direct, muscle energy, for sacral rotation on both same and opposite axes 2. HVLA treatment for sacral rotation on both same and opposite axes 3. Counterstain treatment of sacral tender points and of sacral torsion Counterstrain Multifidi and Rotatores : UP5L Gluteii – maximus: HFO-SI, HI, P 3L- P 4L ,medius, minimus Piriformis Background and Basis The 4 Osteopathic Tenets (Principles) 1. The body is a unit; the person is a unit of body, mind, and spirit. 2. Structure and function are reciprocally inter-related. 3. The body is capable of self- regulation, self-healing, and health maintenance. 4. Rational treatment is based upon an understanding of these basic principles. Somatic Dysfunction - Defined • “Impaired or altered function of related components of the somatic (body framework) system: • Skeletal, arthrodial, and myofascial structures, • And… • Related vascular, lymphatic, and neural elements” Treatment Options for Somatic Dysfunctions All somatic dysfunctions have a restrictive barrier which are considered “pathologic” This restriction inhibits movement in one direction which causes asymmetry within the joint: The goal of osteopathic treament is to eliminate the restrictive barrier thus restoring symmetry…. Somatic Dysfunction: CHARACTERISTICS “The acronym TART is used to remember the abnormal changes that accompany somatic dysfunction. (Tenderness by itself is not always an indication of somatic dysfunction): •Tissue texture changes •Asymmetry •Restricted range of motion •Tenderness Kimberly Manual, chapter 3 Treatment Methodologies Indirect – movement away from the barrier and more functional than structural Cranial-sacral Counterstrain Balanced ligamentous tension (BLT) Facilitated Positional Release Direct – engagement of the restrictive barrier and movement through it and to it by using the body part as a lever Muscle Energy and MFR HVLA Chapman’s and Lymphatics SACRAL STRUCTURE,LIGAMENTS AND MUSCLES THE SACRUM Means “sacred” because of its density it is the last bone to decay and because it protects the reproductive system Forces on the sacrum Angle of the sacroiliac joint “wedges” the sacrum in an anterior direction Prevents posterior movement Dorsal (posterior) sacroiliac ligaments much stronger than anterior sacroiliac ligaments Purpose: counteract significant pelvic forces pushing apex posteriorly. Major Pelvic Ligaments Iliolumbar from ilia to 5 th lumbar vertebrae Sacrospinous Sacrum to spine of the ischium Sacrotuberous Sacrum to ischial tuberosity Sacroiliac Ligament Covers much of the sacroiliac joint, ant & post Iliolumbar ligaments Stabilizes the 5th (4th) Lumbar vertebrae to the ilia Sacrotuberous Sacrospinous ligament ligament Iliolumbar lig Sacrospinous Sacrotuberous Ligament Runs from lower sacral tubercles to ischial tuberosity Gluteus maximus attachment Tendon of the biceps femoris attachment Connects with fascia of the pelvis from sacrum to ischial tuberosity stabilizes anterior motion Both Sacrospinous & Sacrotuberous stabilize to prevent posterior - superior rotation of the sacral apex around a transverse axis Sacroiliac Ligament Sacroiliac actually three ligaments Anterior or ventral sacroiliac from 3rd sacral segment to lateral preauricular sulcus interosseous sacroiliac massive bond between the upper parts of the joint dorsal sacroiliac Partly covers the interosseous, from lateral sacral crest to PSIS and internal iliac crest. Ventral/Anterior Sacroiliac interosseous Posterior sacroiliac Pelvic muscle attachments from above. Attach to Sacrum Erector Spinae Iliocostalis Longissimus Spinalis Multifidus Attach to Innominates Obliques (internal, external, transverse) Quadratus Lumborum Posterior Muscles Erector Spinae (sacrospinalis and iliocostalis) SACRAL ANATOMICAL AXES Transverse axis Superior : the cranial&primary respiratory mechanism creates motion around this axis Middle : sacral base anterior and posterior (FB/BB) occur around this axis Inferior : the innominates rotate around this axis SACRAL MOTION Respiratory motion: inhalation sacral base moves posteriorly (counter-nutates) Respiratory exhalation: sacral base moves anteriorly (nutates) Inherent (craniosacral)motion: ***Craniosacral flexion-base rotates posteriorly (counter- nutates) Craniosacral extension-base rotates anteriorly (nutates) SACRAL PHYSIOLOGIC AXES • Oblique : both left and right oblique axes are named for the superior pole • Sagittal : includes both mid-sagittal and an infinite number of parasagittal axes • Horizontal : functional axis of sacral flexion/extension occur around this axis (analogous to the middle transverse axis above) (footnote on functional anatomy) Why are the Oblique Axes so significant? They are the Axes of Walking . The walking cycle as it applies to our discussion 1. From a standing ( neutral ) position, when you take a step forward, your weight is shifted onto one lower extremity. 2. This induces spinal column SB to the weight bearing side, and pins the upper pole of the sacrum on the side of the SB. 3. As the free lower extremity swings forward, it carries the free pole of the sacrum anterior, creating rotation of the sacrum about the Oblique Axis, towards the weight bearing extremity. Ex.: RL on LOA RR on ROA Bottom Line: You form Oblique Axes with every step you take! The other aspect of the walking cycle is the movement of the torso. 1. From a standing ( neutra l) position, as you step forward, note how your body compensates. What does your torso do? 2. Answer: Rotates towards the moving lower extremity (ie.: away from the weight bearing lower extremity). Bottom Line: Your spine (most notably Lumbar spine) rotates in the opposite direction of the sacrum in a neutral moving situation. TESTS To make a Sacral Diagnosis you will need to know the following: Static (Pure) Landmarks Sacral base - Ant/ Post ILA -Ant/Post ASIS & PSIS -Sup./Inf. Pubes -Sup./Inf & Ant./Post Mixed Landmarks Sacral Sulcus - Deep/Shallow STL -Tight/ Loose/ Equal Motion Testing Spring test L5 Sacrum •Record Positive Right, Positive Left, or Negative Test Spring Test 1. Find sacral base 2. Place heel of hand over Lumbosacral junction 3. Spring in an Anterior motion 4. Results: a. Positive test = If there is NO springing allowed = Non-neutral condition (AKA Backward torsion ) b. Negative test = If there is springing allowed = Neutral condition. Prone Landmarks Sacral Base Judge whether the tip of the thumb is more anterior on one side than the tip of the thumb on the other side. Can also bring index fingers over onto sacral base and take measurement on the lateralized side. Record which base is anterior. Sacral Sulcus Depth Palpable groove just medial to PSIS. Space between sacral spines and lateral sacral crest. Place thumbs in inferior border of PSIS. Move ½-1” up and medial to PSIS. Push thumb tips on sacral base. Pads of thumbs are on ilium and tips on sacral base. Measure the depth of each sacral sulcus relative to opposite sulcus? Record even, deep, or shallow, comparing one side to the other. Both sides may be shallow or deep as well. Inferior Lateral Angle 1. Place flat of hand over sacrum near its caudal end and identify the coccyx. 2. Thumbs approximately 1” apart. Place thumbs in gluteal area about 1” caudal and on each side of coccyx. 3. Push thumbs cephalad until pads rest on inferior margin of ILA. Take a reading on the lateralized side: Inferior or superior? Possibly even? 4. Move thumbs approximately 1” cephalad from the inferior margin of the ILAs and place the pads of the thumbs over the posterior surface of the ILAs near the apex of the sacrum. 5. Use moderate equal pressure & judge if one side is more anterior or posterior than the other one or are they equal? Record on the lateralized side. 1. Place thumbs on the inferior margin of ILA. 2. Move thumbs inferiorly and laterally from the ILA bilaterally, palpating for the sacrotuberous ligament. 3. Ligament will be found between the ILA and Sacrotuberous the ischial tuberosity on each side. Ligament 4. Press thumbs anteriorly, superiorly, and 45-50 degrees laterally to check the tension on the sacrotuberous ligaments. 5. Are they equal in tension or is one tighter or looser than the other? Note which side is looser and which is tighter, relative to the other side. L5 Locate L5 transverse processes, bilaterally Place thumbs over L5 transverse processes, bilaterally Note relative positions of L5 transverse processes bilaterally Which is anterior? Which is posterior? What is the preference of motion at L5 for Rotation? Record the Rotation of L5, Right, Left, or No Rotation L5 rotates to the opposite side of sacrum and side bends to same side as the sacral axis motion Motion Tests for Sacral Diagnosis ASIS Compression Test Have the patient lie supine. The patient is then asked
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